Health Equations           HEALTH SURVEY
    
Name _______________________________________	  Date_______________

INSTRUCTIONS: Number the blanks that apply to you with either a 1, 2, or 3 - -
		(1) for MILD symptoms (occur once or twice a year)
		(2) for MODERATE symptoms (occur several times a year)
		(3) for SEVERE symptoms (you are aware of it almost constantly)
Leave blank blank if it does not apply to you!

GROUP 1
  1 ___  Acid foods upset
  2 ___  Get chilled, often
  3 ___  "Lump" in throat
  4 ___  Dry mouth-eyes-nose
  5 ___  Pulse speeds after meals
  6 ___  Keyed upÐfail to calm
  7 ___  Cuts heal slowly
  8 ___  Gag easily
  9 ___  Unable to relax; startles easily
10 ___  Extremities cold, clammy
11 ___  Strong light irritates
12 ___  Urine amount reduced
13 ___  Heart pounds after retiring
14 ___  "Nervous" stomach
15 ___  Appetite reduced
16 ___  Cold sweats often
17 ___  Fever easily raised
18 ___  Neuralgia-like pains
19 ___  Staring, blinks little
20 ___  Sour stomach frequent

GROUP 2
21 ___  Joint stiffness after arising
22 ___  Muscle-leg-toe cramps at night
23 ___  "Butterfly" stomach
24 ___  Eyes or nose watery
25 ___  Eyes blink often
26 ___  Eyelids swollen, puffy
27 ___  Indigestion soon after meals
28 ___  Always seems hungry; feels "lightheaded" often
29 ___  Digestion rapid
30 ___  Vomiting frequent
31 ___  Hoarseness frequent
32 ___  Breathing irregular
33 ___  Pulse slow; feels "irregular"
34 ___  Gagging reflex slow
35 ___  Difficulty swallowing
36 ___  Constipation, diarrhea alternating
37 ___  "Slow starter"
38 ___  Get "chilled" frequently
39 ___  Perspire easily
40 ___  Circulation poor, sensitive to cold
41 ___  Subject to colds, asthma, bronchitis

GROUP 3
42 ___  Eat when nervous
43 ___  Excessive appetite
44 ___  Hungry between meals
45 ___  Irritable before meals
46 ___  Get "shaky" if hungry
47 ___  Fatigue, eating relieves
48 ___  "Lightheaded" if meals delayed
49 ___  Heart palpitates if meals missed or delayed
50 ___  Afternoon headaches
51 ___  Overeating sweets upsets
52 ___  Awaken after few hours sleepÐ-hard to get back to sleep
53 ___  Crave candy or coffee in afternoons
54 ___  Moods of depressionÐ "blues" or melancholy
55 ___  Abnormal craving for sweets or snacks

GROUP 4
56 ___  Hands and feet go to sleep easily, numbness
57 ___  Sigh frequently, "air hungry"
58 ___  Aware of "breathing heavily"
59 ___  High altitude discomfort
60 ___  Opens windows in closed room
61 ___  Susceptible to colds & fevers
62 ___  Afternoon "yawner"
63 ___  Get drowsy often
64 ___  Swollen ankles, worse at night
65 ___  Muscle cramps, worse during exercise; get "charley horses"
66 ___  Shortness of breath on exertion
67 ___  Dull pain in chest or radiating into left arm, worse on exertion
68 ___  Bruise easily, "black/blue" spots
69 ___  Tendency to anemia
70 ___  Nose bleeds frequent
71 ___  Noises in head or "ringing in	ears"
72 ___  Tension under breastbone, or feeling of tightness, worse on exertion

GROUP 5
73 ___  Dizziness
74 ___  Dry skin
75 ___  Burning feet
76 ___  Blurred vision
77 ___  Itching skin and feet
78 ___  Excessive falling hair
79 ___  Frequent skin rashes
80 ___  Bitter, metallic taste in mouth in mornings
81 ___  Bowel movements painful or difficult
82 ___  Worrier, feels insecure
83 ___  Feeling queasy; headache over eyes
84 ___  Greasy foods upset
85 ___  Stools light-colored

GROUP 6
  98 ___  Loss of taste for meat
  99 ___  Lower bowel gas several hours after eating
100 ___  Burning stomach sensations, eating relieves
101 ___  Coated tongue
102 ___  Pass large amounts of foul smelling gas
103 ___  Indigestion 1/2 -1 hour after eating; may be up to 3-4 hrs.
104 ___  Mucus colitis or "irritable bowel"
105 ___  Gas shortly after eating
106 ___  Stomach "bloating" after eating

GROUP 7
		(A)
107 ___  Insomnia
108 ___  Nervousness
109 ___  CanÕt gain weight
110 ___  Intolerance to heat
111 ___  Highly emotional
112 ___  Flush easily
113 ___  Night sweats
114 ___  Thin, moist skin
115 ___  Inward trembling
116 ___  Heart palpitates
117 ___  Increased appetite without weight gain
118 ___  Pulse fast at rest
119 ___  Eyelids and face twitch
120 ___  Irritable and restless
121 ___  CanÕt work under pressure

		(B)
122 ___  Increase in weight
123 ___  Decrease in appetite
124 ___  Fatigue easily
125 ___  Ringing in ears
126 ___  Sleepy during day
127 ___  Sensitive to cold
128 ___  Dry or scaly skin
129 ___  Constipation
130 ___  Mental sluggishness
131 ___  Hair coarse, falls out
132 ___  Headache upon arising, wears off during day
133 ___  Slow pulse, below 65
134 ___  Frequency of urination
135 ___  Impaired hearing
136 ___  Reduced initiative

		(C)
137 ___  Failing memory
138 ___  Low blood pressure
139 ___  Increased sex drive
140 ___  Headaches, "splitting or rending" type
141 ___  Decreased sugar tolerance

		(D)
142 ___  Abnormal thirst
143 ___  Bloating of abdomen
144 ___  Weight gain around hips or waist
145 ___   Sex drive reduced or lacking
146 ___  Tendency to ulcers, colitis
147 ___  Increased sugar tolerance
148 ___  Women: menstrual disorders
149 ___  Young girls: lack of menstrual function

		(E)
150 ___  Dizziness
151 ___  Headaches
152 ___  Hot flashes
153 ___  Increased blood pressure
154 ___  Hair growth on face or body (female)
155 ___  Sugar in urine (not diabetes)
156 ___  Masculine tendencies (female)

		(F)
157 ___  Weakness, dizziness
158 ___  Chronic fatigue
159 ___  Low blood pressure
160 ___  Nails weak, ridged
161 ___  Tendency to hives
162 ___  Arthritic tendencies
163 ___  Perspiration increases
164 ___  Bowel disorders
165 ___  Poor circulation
166 ___  Swollen ankles
167 ___  Crave salt
168 ___  Brown spots or bronzing of skin
169 ___  Allergies Ð tendency to asthma
170 ___  Weakness after colds, influenza
171 ___  Exhaustion Ð muscular and nervous
172 ___  Respiratory disorders

FEMALE ONLY
173 ___  Very easily fatigued
174 ___  Premenstrual tension
175 ___  Painful menses
176 ___  Depressed feelings before menstruation
177 ___  Menstruation excessive and prolonged
178 ___  Painful breasts
179 ___  Menstruate too frequently
180 ___  Vaginal discharge
181 ___  Hysterectomy/ovaries removed
182 ___  Menopausal hot flashes
183 ___  Menses scanty or missed
184 ___  Acne, worse at menses 
185 ___  Depression of long standing

MALE ONLY
186 ___  Prostate trouble
187 ___  Urination difficult or dribbling
188 ___  Night urination frequent
189 ___  Depression
190 ___  Pain on inside of legs or heels
191 ___  Feeling of incomplete bowel evacuation
192 ___  Lack of energy
193 ___  Migrating aches and pains
194 ___  Tire too easily
195 ___  Avoids activity
196 ___  Leg nervousness at night
197 ___  Diminished sex drive

IMPORTANT
Please list the five main health complaints you have
--in order of their importance, most important first:

1._______________________________________________

2._______________________________________________

3._______________________________________________

4._______________________________________________

5._______________________________________________